A PREGNANT PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS Brain 1. Psychosis 2. Seizures Lungs 1. Intertitial pneumonitis 2. Fibrosing alveolitis Blood vessels 1. Vasulitis Kidneys 1. Lupus nephritis 2. Nephrotic syndrome Skin Face 1. Erythema 2. Butterfly Rash Heart 1. Pericarditis 2. Verrucous Endocarditis 3. Anginal Attacks Spleen 1. — 2. — Skin 1. Bullae 2. — Joints 1. Arthritis Therapeutic Management ● Prior to pregnancy, a patient may be taking a combination of NSAIDS, LAIVH. salicylates, hydroxychloroquine, low- dose prednisone, or szathiaorine lan immunosuppressant) to reduce disease symptoms. They can continue these during pregnancy if used with caution but may be asked to reduce the dose of salicylates 2 weeks prior to labor to prevent bleeding in the newborn and premature closure of the ductus arteriosus. ● The chief complication of the disorder-acute nephritis with glomerular destruction-may occur for the first time during pregnancy. Frequent monitoring of serum creatinine levels will be necessary to assess if kidney function is adequate. If this value is over 1.5 mg/d. and proteinuria and a decreased creatinine clearance value are also present, the fetus is seriously threatened with growth restriction and the pregnancy is also threatened to be preterm. - - During labor, IV hydrocortisone may be administered to help a patient adjust to stress at this time. During the postpartum period, there may be an acute exacerbation of symptoms as corticosteroid levels again fall to normal. Infants of those with SLE may be born with lupus-like rashes, anemia, thrombocytopenia (low platelet count), and neonatal heart block. Such newborn symptoms last about 6 months and then fade. If congenital heart block occurs, a newbor pacemaker may be necessary. Screening for the exact type of autoantibodies present may be helpful in predicting which newborns will be susceptible to this. GI Disorders and Pregnancy - minor Gl discomforts (such as nausea, heartburn, and constipation) are common during pregnancy, acute abdominal pain and protracted vomiting (a risk for dehydration) can lead to complications such as premature separation of the placenta or ectopic pregnancy. A PREGNANT PATIENT WITH APPENDICITIS - The incidence of appendicitis, or inflammation of the appendix, is high in late adolescence and occurs as frequently as one in 1,500 to 2,000 pregnancies (Weinstein et al., 2020) APPENDICITIS SYMPTOMS ● Vomiting ● Loss of Appetite ● Abdominal bloating ● Diarrhea ● Pain in the right side ● Fever [insert picture] - The patient's temperature is usually elevated, a urine sample reveals ketones, and a complete blood count reveals leukocytosis. Because pregnant patients typically have an elevated white blood cell (WBC) count, however, an elevated WBC is not as diagnostic in pregnancy as it might be otherwise. An ultrasound or magnetic resonance imaging (MRI) scan will confirm the inflamed appendix. Therapeutic Management - If a patient is near term (37 weeks) and the fetus is believed to be mature, a cesarean birth may be performed along with removal of the inflamed appendix at the same time. If appendicitis occurs early in pregnancy, the inflamed appendix is usually removed by laparoscopy. - Gastroesophageal reflux disease (GERD) refers to the reflux of acid stomach secretions into the esophagus (Young et al., 2020) Hiatal hernia is a condition in which a portion of the stomach extends and protrudes up through the diaphragm into the esophagus, trapping stomach acid and causing it to reflux into the esophagus. [insert image of types of hiatal hernia] SIGNS YOU MIGHT HAVE A HIATAL HERNIA: - pain in your chest - trouble swallowing - shortness of breath - vomiting blood - regurgitating food back into your mouth Symptoms include: - Heartburn, which is particularly extreme when lying supine after a full meal - Gastric regurgitation - Dysphagia (difficulty swallowing) - Possible weight loss because of the stomach pain - Hematemesis (i.e., vomiting of blood) if extreme esophageal irritation occur Gastroesophageal Reflux Disease – Management During Pregnancy ● Lifestyle Modifications ● Antacids (Avoid sodium bicarbonate and magnesium trisilicate) ● Sucralfate ● Histamine, Receptor Antagonists (preferably ranitidine) ● Proton Pump Inhibitors A PREGNANT PATIENT WITH CHOLECYSTITIS AND CHOLELITHIASIS - Cholecystitis (i.e., gallbladder inflammation) and cholelithiasis (i.e., gallstone formation) are most frequently associated with patients older than 40 years, who are obese, are multiparas, and ingest a high-fat diet. SYMPTOMS OF GALLSTONES - Nausea Vomiting - Heartburn - Belching - Weakness - Increased body temperature - Jaundice - Flatulence - Medical therapy to prevent both conditions is to lower fat intake; however, during pregnancy, patients should not eliminate it entirely because of the importance of linoleic acid for fetal brain growth. If symptoms of acute cholecystitis occur during pregnancy, the condition can be diagnosed by ultrasound. It can generally be managed by temporarily halting oral intake to rest the Gl tract and administering IV fluids to provide fluid and nutrients as well as analgesics for pain. Surgery for gallbladder removal by laparoscopic technique may be done during pregnancy if a patient's symptoms cannot be controlled by conservative management: - A PREGNANT PATIENT WITH PANCREATITIS - Pancreatitis (i.e., inflammation of the pancreas) is a rare disorder that tends to occur in late adolescence and so may occur during pregnancy. - The patient experiences severe epigastric pain, nausea, vomiting, anorexia, and fever. Diagnosis may be difficult as serum amylase, which rises with pancreatitis, is also normally elevated during pregnancy, If serum amylase levels are greater than two times above normal, however, pancreatitis should be suspected Therapeutic Management The disorder is treated the same during pregnancy as in nonpregnant patients: nasogastric suction, bowel rest, analgesia (because pancreatic pain is sharp), and IV hydration through parenteral nutritional supplementation. The inflammation usually subsides within a week. Pregnancy loss, however, can occur from acidosis, hypovolemia, and fetal hypoxia (Cruclat et al., 2020). A PREGNANT PATIENT WITH HEPATITIS - Hepatitis is a liver disease that occurs from invasion of the hepatitis A, B, C, D, or E virus. - Hepatitis A is spread mainly by fecal-oral contact (children in day care settings have a high incidence) or by ingestion of fecally contaminated water or shellfish, It has an incubation period of 2 to 6 weeks. Pregnant individuals exposed to hepatitis A may be given prophylactic gamma- globulin to try to prevent the disease after exposure. This form follows a rather benign course and is not thought to be transmitted to the fetus - Hepatitis B and C are spread by exposure to contaminated blood or blood products or by contact with contaminated semen or vaginal secretions (and so are considered sexually transmitted infections [STIs]) - Hepatitis D and E are apparently spread by the same methods as hepatitis B and C but are rarely seen in pregnancy - Hepatitis B occurs about one in every 2,000 pregnancies (Wilkins et al., 2019). It has an incubation period of 6 weeks to 6 months. [insert image of Types of Hepatitis] Therapeutic Management - Bedrest - High caloric diet - Newborn ( dose of Hbig additional immunization) Ulcerative Colitis - Is a chronic Inflammatory Bowel Disease (IBD) which only affects the lining of the colon - The lining of the colon becomes inflamed and develops tiny open sores, or ulcers that produce pus and mucus - The cause of these diseases is unknown, but an autoimmune process is thought to be responsible. They are also associated with passive and active smoking (Ho et al., 2019). In both diseases, the bowel develops shallow ulcers. A patient experiences chronic diarrhea, weight loss, occult blood in stool, and nausea and vomiting. If extreme, obstruction and fistula formation with peritonitis can occur - With Crohn disease, malabsorption, particularly of vitamin B (the absorption of which occurs almost entirely in the ileum), can occur. Therapeutic Management - Total parenteral nutrition Drug of choice: 1. SULFASALAZINE (AZULFIDINE) ANTI - INFLAMMATORY 2. THIOPURINE IMMUNOMODULATORS LIKE AZATHIOPRINE (AZA) 3. MERCAPTOPRINE (6-MP) 4. INFLIXIMAB (IFX) AND ANDALIMUMAB (ADA) TUMOR NECROSIS FACTOR INHIBITORS Neurologic Disorders and Pregnancy - Neurologic illness, as a whole, does not occur at a high incidence in people of childbearing age. - However, any neurologic disease with symptoms of seizures must be carefully managed during pregnancy because the anoxia that could be caused by severe seizures could deprive a fetus of oxygen A PREGNANT PATIENT WITH A SEIZURE DISORDER - Recurrent seizures have several causes, such as head trauma or meningitis. However, the causes of most recurrent seizures, such as epilepsy, are unknown (i.e., are idiopathic), Recurrent seizures are seen in about three to five pregnant patients per 1,000 births. Therapeutic Management - DRUG OF CHOICE: 1. VALPORIC ACID (CATEGORY D) 2. CARBAMAZEPINE (TERETOL, CATEGORY D) 3. ETHOSUXIMIDE (ZARONTIN, CATEGORY C) 4. FOR ABSENCE SEIZURE PHENYTOIN SODUIM (DILANTIN, CATEGORY DI MAY INCRESE BP HENCE CONSTANT MONITORTING IS NEEDED. - VITAMIN K DEFICIENCY, COGNATIVE IMPAIREMENT AND ATYPICAL FACIAL PROPORTION FOR THE NEWBORN MAY BE PRESENT. VIT K IS PRESCRIBED AT THE LAST 4 WEEKS OF GESTATION. A PREGNANT PATIENT WITH MYASTHENIA GRAVIS - Myasthenia gravis is an autoimmune disorder characterized by the presence of an IgG antibody against acetylcholine receptors in striated muscle. The presence of the antibody causes failure of the striated muscles to contract, particularly those of the oropharyngeal, facial, and extraocular groups. The disorder usually occurs in 20- to 30-year-olds, although it also is seen in young children. Therapeutic management Drug of choice: 1. pyridostigmine (Mestinon) 2. neostigmine (prostigmin) atropine as antidote for overdose 3. corticosteroid 4. magnesium sulfate (combat preterm labor and or elevated bp) 5. Plasmapheresis • Note: newborn may have symptoms because of the transfer of antibodies. A PREGNANT PATIENT WITH MULTIPLE SCLEROSIS - Multiple sclerosis (MS) occurs predominantly in individuals of childbearing age, usually between 20 and 40 years of age (MacDonald et al., 2019). With MS, nerve fibers become demyelinated and therefore lose function. Patients with MS develop symptoms of fatigue, numbness, blurred vision, and loss of coordination. Therapeutic Management - Drug of choice: 1. ACTH ( ADRENOCORTICOTROPIC HORMONE) 2. CORTICOSTERIOD 3. CYCLOSPORINE (SANDIMMUNE) IMMUNOSUPPRESANT 4. AZATHIOPRINE (IMURAN) 5. CYCLOPHOHAMIDE (CYTOXAN) - PLASMAPHERESIS A PREGNANT PATIENT WITH SCOLIOSIS - Scoliosis (i.e., lateral curvature of the spine) begins to be noticed first in young people between 12 and 14 years of age. If it is uncorrected at this time, the curvature progresses until it can interfere with respiration and heart action because of chest compression. Pelvic distortion can interfere with childbirth, especially at the pelvic inlet. THERAPEUTIC MANAGEMENT PREPREGNANT - (BODY BRACE) CESAREAN BIRTH TO ENSURE SAFE DELIVERY A PREGNANT PATIENT WITH A THYROID DYSFUNCTION - A Pregnant Patient With Hypothyroidism - Hypothyroidism, or underproduction of the thyroid hormone, is a rare condition in late adolescence MANAGEMENT: - LEVOTHYROXINE (SYNTHROID) - A Pregnant Patient With Hyperthyroidism - Hyperthyroidism, or overproduction of thyroid hormone, causes symptoms such as a rapid heart rate, exophthalmos (i.e,, protruding eyeballs), heart intolerance, hean palpitations , and weight loss, Sometimes called Graves disease, it is present in 0.1% to 0.4% of pregnancies. - MANAGEMENT: TAPAZOLE (METHIMAZOLE) PR PTU (PROPYLTHIDURACIL) ● NOTE: an infant may be born with symptoms of hyperthyroidism because of the excess stimulation they receive in utero. The newborn may appear jittery with tachypnea and tachycardia. ● SURGICAL TREATMENT MAY BE DONE BUT THIS IS GENERALLY NOT A CHICE OF TX DURING PREGNANCY. A PREGNANT PATIENT WITH DIABETES MELLITUS - Now that both type 1 and type 2 diabetes can be well managed, several new challenges have developed: • How to manage both type 1 and type 2 diabetes during pregnancy to achieve a healthy glucose/ insulin balance during pregnancy • How to protect an infant in utero from the adverse effects of increased glucose levels • How to care for the infant in the first 24 hours after birth until the infant's insulin-glucose regulatory mechanism stabilizes Diabetes During Pregnancy - In all pregancies, the glomerular filtration of glucose is increased (the glomerular excretion threshold is lowered), causing slight glycosuria - Has a high risk of developing hypoglycemia and ketoacidosis because of the fetal requirement needed. If the patient has pre existing kidney problems (shows thru proteinuria, decreased in creatinine clearance and hypertension) the risk for hpn will increase remarkably. - The first trimester of pregnancy is the most important time for fetal development; if a pregnant patient can be kept from becoming hyperglycemia during this time, the chances of a congenital anomaly are greatly lessened. [insert images of Diabetes Complications, Classification of Diabetes Mellitus] Risk factors for developing gestational diabetes include: - Obesity - Age over 25 years - History of large babies (10 lb or more) - History of unexplained fetal or perinatal loss - History of congenital anomalies in previous pregnancies - History of polycystic ovary syndrome - Family history of diabetes (one close relative or two distant ones) - Member of a population with a high risk of diabetes [insert image of assessment] Monitoring a Pregnant Patient With Diabetes - The best insulin control program during pregnancy can then be determined. The measurement of glycosylated hemoglobin (HbA1c), a measure of the amount of glucose attached to hemoglobin, is used to detect the degree of hypert cemia present. - The average blood glucose level over the past 4 to 6 weeks (i.e the time the hemoglobin in red blood cells were picking up the glucose). The teer normal level of HbA1c is 6% of total hemoglobin. - Urine culture for asymptomatic UTI. - Ophthalmic exam (increased exudate, dot hemorrhage, and macular edema, can progress or originate during pregnancy) [image of therapeutic management] Tests for Placental Function and Fetal Well-Being • Alpha feto-protein level test at 15-17 weeks aog FOR NEURAL TUBE DEFECT • UTZ AT 18-20 WEEKS FOR GROSS ABNORMALITIES. • CREATININE LEVELS AT EACH TRIMESTER. • SELF MONITOR FOR FETAL MOVEMENT (10 FETAL KICKS) • UTZ AT 28, 36-38 WEEKS AOG FOR FETAL GROWTH, AMNIOTIC FLUID, BIOPHYSICAL PROFILE, PLACENTAL LOCATION, AND BIPARIETAL DIAMETER. Timing for Birth - Cesarean birth was chosen because it is difficult to induce labor this early in pregnancy because the cervix is not yet ripe or responsive to labor contractions; babies of patients with diabetes are large, making vaginal birth difficult; and a fetus suffering placental dysfunction or insufficiency did not do well in labor. Today, when an accurate assessment of fetal age to available by ultrasound making and the pregnancy can be maintained within safe limits by the use of nonstress bleeding for a longest period, the last weeks of pregnancy are not as hazardous as before, and the string and type of birth are much more individualized. If at all possible, vaginal birth is preferred. Labor may be induced by rupture of the membranes or an oxytocin infusion after measures to induce cervical ripening. • A patient's glucose level is regulated during labor by an IV infusion of short-acting or regular insulin with frequent blood glucose assays to prevent hypoglycemia in the patient or rebound hypoglycemia in the newborn. •To prevent hyperglycemia from developing: Ringer's lactate or 0.9% saline is infused instead Postpartum Adjustment •2h postprandial glucose test after giving birth Mental Illness and Pregnancy - Any psychotropic medication taken by a pregnant patient should be evaluated before pregnancy for possible fetal harm (Raffi et al., 2019). For example, lithium, a mainstay of therapy for mood disorders such as bipolar disorder, and serotonin-reuptake inhibitors, used to counteract depression, have potential considerations for fetal exposure during pregnancy, like cardiac malformations or pulmonary hypertension, respectively
